Mumma , et al . ( 2018 ) performed a human factors risk analysis of doffing practices for
Ebola-level PPE to assess the relationship between errors and selfcontamination and found that hand hygiene and removal of the powered air-purifying respirator contributed most to infection risk and errors .
• described by Birnbach , et al . and Suresh , et al . or failed interventions , like that described by Rashidi et al . and D ’ Egidio , et al . if they apply the HFE principles of salience , perception and attention , and effective display design . For example , dispensers designed based on the principle of salience ( e . g ., bright color , unique shape , context sensitive blinking lights or audio ) could help healthcare workers more easily perceive dispensers in the patient care zone , and remind them to ‘ attend ’ to hand hygiene more consistently .” Calling attention to dispensers with blinking LED lights increases hand hygiene adherence , according to Nevo , et al . ( 2010 ), while Muder , et al . ( 2008 ) found that demarcating the space around a patient by placing markers or tape on the floor also worked .
Carter , et al . examined how physical layout affects hand hygiene compliance and found that compliance was lowest when the emergency department was most crowded and was lower in hallway areas than in semiprivate areas . In addition , the location of hand sanitizing products within the geographical space of the care environment significantly affects compliance . Birnbach , et al . found that dispenser location and visibility within patient rooms — immediately adjacent to the patient versus across from the patient ’ s bed and not clearly visible — significantly affected hand hygiene adherence . Suresh , et al . found deficiencies in the structural layout of healthcare institutions that could hinder use of dispensers , such as being in locations where healthcare workers could not see or access them easily or in locations that did not facilitate their use within the sequence of care .
Other research has concluded that multimodal interventions are more effective than singular interventions ( Huis et al ., 2012 ; Naikoba and Hayward , 2001 ; Pincock , et al ., 2012 ), and World Health Organization guidelines ( WHO , 2009 ) recommend changes in five areas : system level , education and training , evaluation and feedback , reminders in the workplace , and institutional safety climate .
Pennathur and Herwaldt ( 2017 ) remind us that studies have assessed whether organizational factors such as leadership , organizational support and culture , and coordination mechanisms ( e . g ., huddles ), affect hand hygiene compliance .
As Drews , et al . ( 2020 ) summarize , “ Hand hygiene adherence can be improved by carefully considering dispenser usability , workflow , and other aspects of the sociotechnical system . In the same vein , HCP mental models need to be better understood and their accuracy improved . Future HFE work can increase our understanding of how to improve hand hygiene adherence further .”
HFE and PPE
Proper donning , use and doffing of personal protective equipment ( PPE ) protects healthcare personnel from potential exposure to contaminated body fluids as well as from exposure to organisms transmitted via contact , droplet , or airborne routes , but Drews , et al . ( 2020 ) emphasize that correct PPE use “ intersects equipment , user , and environments ( physical , social , and policy ).” They add , “ Three phases of PPE use can lead to potential contamination : donning , patient care , and doffing . During donning , contamination risks are associated with improper storage of the PPE , previous PPE exposure to germs , or incorrect technique . During patient care , risks include damaging the PPE , design flaws , and sidestepping PPE due to distraction ( i . e ., reaching for a cell phone under the PPE ). Doffing risk is due to incorrect PPE removal , incorrect handling and disposal of PPE , or damaging PPE .”
Numerous studies have found that healthcare personnel ( HCP ) lack understanding of proper PPE use , as well as identifying that literature and guidelines lacked necessary detail and even provided ambiguous or contradictory removal recommendations , resulting in contamination risk .
In their examination of PPE use by healthcare workers for common pathogens , Beam , et al . ( 2011 ) found that all the participants committed at least one PPE breach , with breaches occurring during all three phases . Donning issues included failure to perform a respirator seal check , failure to tie the gown at the neck and waist , and improper donning sequence . Doffing breaches included deviations from correct doffing sequence and improper mask removal . In addition , HCP brought out potentially contaminated items during room exit . Common breaches during care included touching HCP ' s unprotected body areas with contaminated PPE . Overall , the authors concluded that HCP understanding of contamination pathways needed improvement and simulator studies help gain insights into nonadherence . Similarly , Zellmer , et al . ( 2015 ) found 57 percent of HCP doffed PPE in an incorrect order , 53 percent failed to remove contaminated PPE before room exit , and 40 percent disposed of PPE incorrectly . Mitchell , et al . ( 2013 ) found that 66 percent of all HCP failed to don the recommended PPE , and 56 percent doffed in an incorrect sequence .
Mumma , et al . ( 2018 ) performed a human factors risk analysis of doffing practices for Ebola-level PPE to assess the relationship between errors and self-contamination and found that hand hygiene and removal of the powered air-purifying respirator contributed most to infection risk and errors . The authors emphasize that PPE can protect but also endanger HCP , highlighting the importance of equipment design that reduces the potential for endangering HCP .
By applying an HFE analytical framework , Krein et al . ( 2018 ) identified and characterized failures in PPE use , focusing on self-contamination events . Of the 283 observed failures , 102 were categorized as violations , 144 as process / procedural mistakes , and 37 as slips . The authors concluded that given the range of contributors to self-contamination events , no single strategy is sufficient to reduce transmission risk . Kang , et al . ( 2017 ) observed contamination in 92 percent of doffing attempts with simple , and in 66 percent with full-body PPE . After receiving training , 91 percent of